Consent for Use of Controlled Medications – Your Labwork
Informed consent for intravenous nutrition therapy with or without chelating agents for heavy metal toxicity. Informed consent for intravenous treatment for arteriosclerosis disease and/or for prevention of disease. Informed consent for intravenous treatment of flu/colds, cancer, chronic fatigue syndrome, immune system support, multiple sclerosis, auto immune diseases, endocrine dysfunction, fibromyalgia, gulf war illness, scleroderma, revitalization after chemo, chronic Lyme disease, shingles, Epstein-Barr, cardiovascular disease, infections, Alzheimer, hepatitis C and AIDS, heavy metal contamination, allergies and others.
I give consent to the doctors and staff at Integrative Health to perform intravenous nutrient therapy, intravenous chelation therapy, intravenous arteriosclerosis therapy and/or any other intravenous therapy deemed by my IH doctor to be beneficial to my care. I understand that the intravenous treatment may contain vitamins, minerals, amino acids, chelating agents (such as DMPS and/or EDTA), glutathione, N-Acetyl-Cysteine, DMSO, procaine, H2o2, alpha lipoic acid, preservative agents, and/or other ingredients as deemed beneficial by my doctor. I understand that any or all of these ingredients may or may not be FDA APPROVED for use intravenously or otherwise.
I have been informed of possible risks and side effects of intravenous therapy including but not limited to severe allergic reactions, discomfort at the injection site, painful and long lasting inflammation of the vein (thrombophlebitis), muscle aches or cramps, bone pain, body odor, low blood calcium, transient dizziness, hypoglycemia, mineral loss, skin rash, kidney irritation and inflammation, nephrotoxicity, congestive heart failure and liver disease. I have disclosed to my physician any known significant clinical conditions including liver, kidney, heart disease, allergies or current pregnancy. I understand that it is my responsibility to report to my treating physician any adverse reactions to the treatment and any changes in my health condition.
I understand that the benefits of intravenous therapy are greater if I eat a healthy diet, drink plenty of water, take extra fiber, get appropriate exercise, get proper sleep and do not smoke. I have not been guaranteed any specific outcome. I understand that I am free to discontinue therapy at any time. I am aware that conventional medicine has other drugs and treatments used for my condition that may differ from the approach I am choosing to use at IH. I understand that I am free to consult with other health care providers at any time regarding my condition. I have not been asked to discontinue care with any other physician or specialist.